ARBAMINCH UNIVERISITY

NECHI SAR HEALTH SCIENCES CAMPAS

SCHOOL OF NURSING
FIRST YEAR POST GRADUATE STUDENT
Assignment Pain Management and Palliative Care

PREPARED BY: Selamawit Fiadeie………PRMSH/078/15

Submitted to: Mr. Agegnehu B. (BSc, MSc, Ass. Prof. )

Submitted date: 11/11//2023

ARBAMINCH ETHIOPIA

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presentation out line

 introduction Pain management and prevention

 Objective Reference
 Definition
 Types of pain
 Sign &Symptom of pain
 Assessment of Pain

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objective
At the end of this seminar presentation the participants will be expected to:
 Define pain
 List the clinical feature of pain
 Describe pain assessment Toole
 Explain pain management &prevention

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Introduction

 Preterm and term newborns demonstrate similar or even exaggerated

physiological and hormonal responses to pain compared with those

observed in older children and adults.

-
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Con…..

 Neonates have less ability to demonstrate pain symptoms and thus

depend on others to recognize, assess, and manage their pain by
recognizing the neonate’s associated behavioral and
physiological responses to pain.

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Con…..

 Exposure to prolonged or severe pain may increase neonatal mortality

and affect long-term neurodevelopmental outcome.

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Definition of Pain

 “…an unpleasant sensory and emotional experience associated with

actual or potential tissue damage, or described in terms of such
damage” (IASP, 1989)

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 Type of Pain

1- Acute pain: Skin-breaking procedures or tissue injury caused by

diagnostic or therapeutic innervation.
2- Established pain: Occurs after surgery, localized inflammatory
conditions birth related trauma
3- Prolonged pain: Results from severe diseases e.g. NEC, mening
4-persisting pain: persisting beyond normal tissue healing time

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 Effects of Pain

1 physiologic effects:
 Tachycardia
 Blood pressure changes (↑ or ↓)
 Increase O2 consumption
 Hypoxemia

 Temperature changes
 Pallor, flushing, sweating
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2 Behavioral Change:

 Change in facial expression:

 Grimace

 eye squeeze
 Deepening nasal furrow nasal flaring
 Crying

 ‘Silent’ cry (intubated babies

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3Body Movement:

 Fisting

 Tremulousness

 Thrashing limbs
 Limb withdrawal
 Cycling

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4 Assessment of Pain

 Babies are unable to report pain. Appropriate and accurate assessment of

pain is necessary and routine element in deciding the need for effective
management of the infants pain, through non-Pharmacological and
where appropriate pharmacological intervention .

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 Cont.……
 Pain should be assessed within one hour of admission and
reassessed daily once per shift or according to each infant needs
to detect for the presence of pain and to evaluate the
effectiveness of treatment .
 For any infant about to undergo a painful procedure, they must
be assessed using the pain assessment tool for 15 seconds prior
to the potentially

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Cont………..
 painful event and then assessed again 30 seconds immediately
following the painful procedure and score must be documented
on the observation chart .
 Post operatively pain should be assessed hourly for first 8 hr.
then 4-hrly until48 hr. (more frequently if signs of
distress/discomfort)

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The Pain Assessment Tool (PAT)

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Cont.……….
 Advised Interventions Required:
- PAT Score <5: Nursing Comfort Measures (NCM)
- PAT Score >5: Paracetamol and NCM
- PAT Score >10: Paracetamol, NCM and opioid (bolus/ infusion to be
commenced)

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Guidelines for pain management

Prevent or minimize pain:

 Reduce number of needle punctures by drawing blood tests at one time if
feasible.
 Use indwelling venous or arterial catheters when appropriate
 Select most competent staff to perform invasive procedures.

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Cont……

 Use minimal amount of tape and remove tape gently.

 Ensure proper premedication before invasive procedures
 Use appropriate equipment (smallest gauge needle)
 Decrease environmental stimuli (light, noise, abrupt movements)

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Treatment guidelines

 Assess each infant on an individual basis. Using the pAT, PIPP the
nurse and the medical team determine a pain score and the
appropriate intervention for pain management .

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Non pharmacologic measures

 Non-pharmacological measures are environmental and behavioral

interventions that do not use pharmacological agents. The following
measure are followed to minimize pain such as.
 Avoid bright light, loud noise
 Limit the number of painful procedures and handling.

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cont

■ Tactile stimulation like stroking, massaging.

■ Gently repositioning baby.
■ Reducing light, noise and activity around
baby's.

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Con…..

 Nappy change
 Kangaroo care.
 Mother’s expressed breast milk
 MUSIC

 Non-nutritive sucking using pacifiers

(dummy or gloved finger).

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Pharmacological measures

 Analgesics are the mainstay of pharmacologic treatment of pain

 Sucrose and Glucose
 Local anesthetic agent
 Systemic agents: opioids, acetaminophen(paracetamol)

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Cont…..
 N.B Non-steroidal anti-inflammatory agents(NSAID) are generally not
used in newborns as analgesics.

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Sucrose analgesia

 Sucrose administration is particularly useful for short procedures like venipuncture heel

prick, etc.
 Oral administration of concentrated sucrose solution (24%to 50%) acts through the

release of endogenous opioids like beta-endorphin Analgesic effect lasts for five to eight

minutes.

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Sucrose/glucose should be used with caution in:

 Infants at high risk of developing necrotizing enter colitis

(NEC)
 Infants with hyperglycemia
 Newborn infants of opiate-dependent mothers – these infants
may have altered endogenous opioid systems reducing the
analgesic effect of oral sucrose
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Sucrose/glucose should not be given to:

 Infants with known fructose or sucrose intolerance

 Infants with teeth as sucrose/glucose can bind to the enamel and cause
tooth decay
 Infants who are muscle relaxed

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Local an aesthetics

 Local an aesthesia is particularly useful for management of

acute procedures related with the exception of heel lances. It
can be either topically applied on intact skin or injected
subcutaneous.
The common topical preparations marketed are:
1 Eutectic mixture of local anesthetics (EMLA): is a mixture of
two local anesthetics namely. Lidocaine and prilocain that is
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 Cont.…..
2 Tetracaine (4%)

The dose of EMLA is 1–2g with a contact period of 30 minutes to 1one hour. Apply the

cream over a 2–3 cm area with a 1–2mm thickness and cover with

transparent(tegaderm) dressing. For maximal analgesic effect, the topical an aesthetics

should be combined with other non-pharmacological measures like sucrose analgesia or

breast milk supple mention

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Acetaminophen

 Acetamiophen (paracetamol) is the only antipyretic available for use in

neonates. It is also a weak analgesic, which if administered alone,
is not effective enough to reduce acute severe pain However, it can be
combined with opioids in the setting of postoperative pain to reduce the
amount of opioids needed .

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Cont.…

 it is also used alone for mild to moderate inflammatory pain (eg,

necrotizing enter colitis, skin wounds, bedsores, or nasal trauma due to
nasal ventilation) or limb pain (e.g., limb bruises, clavicle fractures, or
cephalohematoma or caput succedaneum following birth trauma).

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Con.….
 formulation and dosing — In infants, oral, rectal, and
intravenous (IV) formulations of acetaminophen are available
 Total daily dose – Recommended total daily doses are based on
gestational age (GA) and postnatal age
 24 to 30 weeks GA – 20 to 30 mg/kg/day
 31 to 36 weeks GA – 35 to 50 mg/kg/day

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Con……..

 37 to 42 weeks GA – 50 to 60 mg/kg/day
1 to 3 months postnatal age– 60 to 75 mg/kg/day

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Opioids

 Opioids are the most effective therapy for moderate to severe pain in
patients of all ages.
Indications for continuous infusion of opioids in ventilated neonates
are
 Post-operative patients especially in the first 48-72 hr.

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Cont.…….

 Illnesses like meconium aspiration syndrome or congential

diaphragmatic hernia with PPHN.
 Asynchrony or fighting with a ventilator rule out causes like
ventilator mal function, tube block or inappropriate settings before
the infant is sedated for this indication .

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Weaning of Opiate analgesics

 Weaning from morphine/ fentanyl should be done if the agents

have been given routinely for more than 3 days
 Method of weaning depends upon length of opiate therapy:
 1. Short term therapy (<1 week): Initially reduce dose by
20%. Then reduce dose by10% q6-8h

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Con…….

2.Long term therapy (>1 week): Reduce dose by 20% over first 24h.
Then reduce dose by 10% q12h as tolerated. Drug can usually be
discontinued when it is at about 20% of original dose, although subsequent
small doses may be needed.

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Analgesic measures for specific procedures

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DEFINTION

 Palliative care for neonates is a specialized form of care that focuses on

providing comfort and support to infants and their families during a life-
threatening or terminal illness. It is designed to help families cope with
the emotional and physical challenges of caring for a seriously ill or
dying infant.

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Technique of Maternal and Family Counseling

 Maternal and family counseling is a type of counseling that focuses on

helping mothers and their families cope with the challenges.
 There are a number of different techniques that can be used in maternal and
family counseling. Some of the most common include:

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Admission Counseling in Neonate

 Admission counseling is an important part of the care of a neonate. It

helps to ensure that the parents are informed about their baby's condition
and the hospital's policies and procedures. It also helps to build a
relationship between the parents and the healthcare team.

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Foster parent/infant boding

 Be supportive. Foster parents need to feel supported by their

The counselor should provide a safe space for the foster parents
to express their feelings and concerns.
 Be patient It takes time for foster parents to adjust to the
challenges of caring for a child with a health problem. The
health provider should be patient and understanding as the
foster parents learn how to cope
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cont

 .Be realistic. Foster parents need to be realistic about the

challenges they face. They need to understand that their child's
illness may not be cured, and that they may need to provide long-
term care.
 Be flexible. Foster parents need to be flexible and adaptable.
Their child's needs may change over time, and they need to be
able to adjust their parenting style accordingly
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Cont…….

 Set realistic goals. Foster parents need to set realistic goals for
themselves and their child. They need to understand that it will take
time for their child to improve, and that they may need to adjust their
expectations
 Seek professional help. Foster parents may need to seek professional
help to cope with the challenges of caring for a child with a health
problem. They may need help with parenting, stress management, or
grief and loss.
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DIS CHARGE TEACHING
 Counseling for Temperature regulation , Kangaroo mother care
A
 Advise for exclusive breastfeeding
 Educate for infections prevention
 Tell for vaccination schedule and follow up visiting
 Educate for sunshine exposure and neonatal danger sign

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Reference
 NICU Training participants 2021
 Clinical Reference Manual for Advanced Neonatal care in Ethiopia
 Prevention and Management of Procedural Pain in the
Neonate: An Update
Committee on Fetus and Newborn and section on
Anesthesiology and Pain Medicine

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Con…..
 Pediatrics. From the American Academy of Pediatrics. Policy
Statement. January 2016
 Nottingham Neonatal Service – Clinical guidelines. Oral
Sucrose for the
 management of procedural pain. Ratification Date: 28th June
2016. Review date: June 2019

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Thank you

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